These guidelines apply primarily to newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth.
For purposes of these guidelines, the terms newborn and neonate apply to any infant during the initial hospitalization. The term newly born applies specifically to an infant at the time of birth.
Immediately after birth, infants who are breathing and crying may undergo delayed cord clamping (see Umbilical Cord Management section). However, infants who are not breathing or crying should have the cord clamped, so that resuscitation measures can commence promptly.
Newly born infants who do not require resuscitation can be generally identified upon delivery by rapidly assessing the answers to the following 3 questions:
If the answer to all 3 questions is “yes,” the newly born infant may stay with the mother for routine care. Routine care means the infant is dried, placed skin to skin with the mother, and covered with dry linen to maintain a normal temperature. Observation of breathing, activity, and color must be ongoing.
If the answer to any of the three assessment questions is “no,” the infant should be moved to a radiant warmer to receive 1 or more of the following 4 actions in sequence:
Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required (see Figure):
Readiness for neonatal resuscitation requires:
Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and PPV; that person’s only responsibility should be care of the newborn.
In the presence of significant perinatal risk factors that increase the likelihood of the need for resuscitation, additional personnel with resuscitation skills (including chest compressions, endotracheal intubation, and umbilical vein catheter insertion) should be immediately available.
Because a newborn without apparent risk factors may unexpectedly require resuscitation, each institution should have a procedure in place for rapidly mobilizing a team with complete newborn resuscitation skills for any birth.
A standardized checklist may be helpful to ensure that all necessary supplies and equipment are present and functioning.
A known perinatal risk factor, such as preterm birth, requires preparation of supplies specific to thermoregulation and respiratory support for this vulnerable population.
When perinatal risk factors are identified, a team should be mobilized and a team leader identified.
Until recent years, the umbilical cord was commonly clamped soon after birth to quickly transfer the infant to the neonatal team for stabilization. The 2010 and 2015 international consensus on science review processes identified evidence suggesting that delayed cord clamping might be beneficial for infants that did not need immediate resuscitation at birth.
There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth. We suggest against the routine use of cord milking for infants born at less than 29 weeks of gestation outside of a research setting. (Class IIb, LOE C-LD) (2015 Part 13)
Further study is warranted because cord milking may improve initial mean blood pressure and hematologic indices and reduce intracranial hemorrhage, but thus far there is no evidence for improvement in long-term outcomes.
The initial steps of newborn resuscitation are to:
Admission temperature of newly born nonasphyxiated infants is a strong predictor of mortality at all gestational ages. Preterm infants are especially vulnerable to hypothermia.
Hypothermia is associated with serious morbidities, such as increased risk of intraventricular hemorrhage, respiratory issues, hypoglycemia and late-onset sepsis.
The use of radiant warmers and plastic wrap with a cap has improved but not eliminated the risk of hypothermia in preterm infants in the delivery room. Other strategies have been introduced, which include increased room temperature, thermal mattresses, and the use of warmed humidified resuscitation gases. Various combinations of these strategies may be reasonable to prevent hypothermia in infants born at less than 32 weeks of gestation. (Class IIb, LOE B-R, B-NR, C-LD) (2015 Part 13)
All resuscitation procedures, including endotracheal intubation, chest compression, and insertion of intravenous lines, can be performed with these temperature-controlling interventions in place. (Class IIb, LOE C) (2010 Part 15)
There is insufficient current evidence to recommend a preference for either rapid (0.5°C/hour or greater) or slow rewarming (less than 0.5°C/hour) of unintentionally hypothermic newborns (temperature less than 36°C) at hospital admission. Either approach to rewarming may be reasonable. (Class IIb, LOE C-LD) (2015 Part 13)
Although maternal hyperthermia in labor is associated with adverse neonatal outcomes (increased mortality, neonatal seizures, and adverse neurologic states like encephalopathy) there is insufficient evidence to make a recommendation on the management of maternal hyperthermia. (2015 Part 13)
In resource-limited settings, to maintain body temperature or prevent hypothermia during transition (birth until 1 to 2 hours of life) in well newborn infants, it may be reasonable to put them in a clean food- grade plastic bag up to the level of the neck and swaddle them after drying. (Class IIb, LOE C-LD) (2015 Part 13)
There are no data examining the use of plastic wraps or skin-to-skin contact during resuscitation/stabilization in resource-limited settings.
Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia that can be associated with suctioning of the nasopharynx. In addition, studies from the newborn intensive care unit have demonstrated deterioration in pulmonary compliance, oxygenation, and cerebral blood flow velocity accompanying tracheal suctioning, also suggesting the need for caution in the use of suction immediately after birth.
It is recommended that suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (PPV). (Class IIb, LOE C) (2010 Part 15)
Because the presence of meconium-stained amniotic fluid may indicate fetal distress and increases the risk that the infant will require resuscitation after birth, a team that includes an individual skilled in tracheal intubation should be present at the time of birth.
If the infant is vigorous with good respiratory effort and muscle tone, the infant may stay with the mother to receive the initial steps of newborn care. If necessary, the meconium may be gently cleared from the mouth and nose with a bulb syringe.
If the infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. (Class IIb, LOE C-LD) (2015 Part 13) A definitive randomized clinical trial is still needed.
Emphasis should be made on initiating ventilation within the first minute of life in nonbreathing or ineffectively breathing infants.
Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant. This may include intubation and suction if the airway is obstructed.
During resuscitation, an increase in the newborn’s heart rate is considered the most sensitive indicator of a successful response to each intervention. Therefore, it is critically important to identify a rapid, reliable, and accurate method to measure and monitor the newborn’s heart rate.
Clinical assessment of heart rate has been found to be unreliable and inaccurate. Recent studies have found that a 3-lead electrocardiogram (ECG) displayed a reliable heart rate faster than pulse oximetry, and the pulse oximeter tended to underestimate the newborn’s heart rate (potentially leading to unnecessary interventions).
The use of ECG does not replace the need for pulse oximetry to evaluate the newborn’s oxygenation.
Clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation during the immediate neonatal period and lack of cyanosis appears to be a very poor indicator of the state of oxygenation of an uncompromised baby following birth.
There is evidence that either insufficient or excessive oxygenation can be harmful to the newborn infant.
It is recommended that oximetry be used when resuscitation can be anticipated, when PPV is administered, when central cyanosis persists beyond the first 5 to 10 minutes of life, or when supplementary oxygen is administered. (Class I, LOE B) (2010 Part 15)
To appropriately compare oxygen saturations to published reports of oxygen saturations in newlyborns, the probe should be attached to a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm).
Multiple studies have now documented no survival or neurodevelopmental outcome benefit with the use of 100% oxygen compared with 21% oxygen for initial oxygen concentration, and higher short-term mortality with the use of 100% oxygen. No studies compared intermediate oxygen concentrations (between 21% and 100%) and none compared oxygen concentrations used during chest compressions.
These recommendations refer to initial oxygen concentration, with subsequent titration based on the oxyhemoglobin saturation determined by pulse oximetry at a preductal site, with high value placed on avoiding excessive oxygen exposure.
Oxygen concentration should be titrated to achieve a preductal oxygen saturation approximating the interquartile range (see table in Figure) measured in healthy term babies following vaginal birth at sea level. (Class I, LOE B-R) (2015 Part 13)
Multiple studies in preterm newborns demonstrated no differences in short- or long-term outcomes when respiratory support was initiated with lower oxygen compared with higher oxygen concentration.
In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry. (Class IIb; LOE C-LD) (2019 Neo)
Oxygen concentration should be titrated to achieve a preductal oxygen saturation approximating the interquartile range (see table included in the Figure) measured in healthy term babies following vaginal birth at sea level. (Class I, LOE B-R) (2015 Part 13)
These recommendations reflect a preference for not exposing preterm newborns to additional oxygen without data demonstrating a proven benefit for important outcomes.
Many subpopulations of newborns (eg, those with congenital heart disease or other malformations) have not been studied and many outcomes have not been fully assessed. As noted above, these recommendations refer to initial oxygen concentration with oxygen administration titrated to achieve the preductal oxygen saturations listed in Table 1.
If the infant remains apneic or gasping, or if the heart rate remains <100 per minute after performing the initial steps, begin positive pressure ventilation.
There is insufficient data regarding short and long-term safety and the most appropriate duration and pressure of inflation to support routine application of sustained inflation of greater than 5 seconds’ duration to the transitioning newborn. (Class IIb, LOE B-R) (2015 Part 13) More evidence is needed.
The initial peak inflating pressures needed are variable and unpredictable and should be individualized to achieve an increase in heart rate or movement of the chest with each breath. The first few breaths often require higher pressure than subsequent breaths.
Inflation pressure should be monitored; an initial inflation pressure of 20 cm H2O may be effective, but ≥30 to 40 cm H2O may be required in some term babies without spontaneous ventilation. (Class IIb, LOE C) (2010 Part 15)
If circumstances preclude the use of airway pressure monitoring, the minimal inflation required to achieve an increase in heart rate should be used. There is insufficient evidence to recommend an optimum inflation time.
Administration of PPV is the standard recommended treatment for both preterm and term infants who are apneic. A flow-inflating or self-inflating resuscitation bag or T-piece resuscitator are appropriate devices to use for PPV.
When self-inflating resuscitation bags are used, the addition of a positive end-expiratory pressure (PEEP) valve will be required.
The most appropriate choice of device to deliver PPV may be guided by available resources, local expertise, and preferences. The self- inflating bag remains the only device that can be used when a compressed gas source is not available. Unlike flow-inflating bags or T-piece resuscitators, self-inflating bags cannot deliver continuous positive airway pressure (CPAP) and may not be able to achieve PEEP reliably during PPV, even with a PEEP valve. However, it may take more practice to use a flow-inflating bag effectively. In addition to ease of use, T-piece resuscitators can consistently provide target inflation pressures and longer inspiratory times in mechanical models, but there is insufficient evidence to suggest that these qualities result in improved clinical outcomes.
It is likely that inflation pressures will need to change as the infant’s pulmonary compliance improves following birth, but the relationship of pressures to delivered volume and the optimal volume to deliver with each breath as functional residual capacity is being established have not been studied.
Resuscitators are insensitive to changes in lung compliance, regardless of the device being used. Note to the reader: This statement previously was labeled with a Class and LOE but is a statement of fact. For further information, see Neonatal Guidelines published in 2010. (2010 Part 15)
Laryngeal masks, which fit over the laryngeal inlet, can achieve effective ventilation in term and preterm newborns at 34 weeks or more of gestation. Data are limited for their use in preterm infants delivered at less than 34 weeks of gestation or who weigh less than 2000 g.
A laryngeal mask is recommended during resuscitation of term and preterm newborns at 34 weeks or more of gestation when tracheal intubation is unsuccessful or is not feasible. (Class I, LOE C-EO) (2015 Part 13)
Use of the laryngeal mask has not been evaluated during chest compressions or for administration of emergency medications.
During neonatal resuscitation, endotracheal intubation may be indicated when bag-mask ventilation is ineffective or prolonged, when chest compressions are performed, or for special circumstances such as congenital diaphragmatic hernia.
When PPV is provided through an endotracheal tube, the best indicator of successful endotracheal intubation with successful inflation and aeration of the lungs is a prompt increase in heart rate.
Exhaled CO2 detection remains the most reliable method of confirmation of endotracheal tube placement.
A positive test result (detection of exhaled CO2) in patients with adequate cardiac output confirms placement of the endotracheal tube within the trachea, whereas a negative test result (ie, no CO2 detected) strongly suggests esophageal intubation.
Failure to detect exhaled CO2 in neonates with adequate cardiac output strongly suggests esophageal intubation.
Poor or absent pulmonary blood flow (eg, during cardiac arrest) may result in failure to detect exhaled CO2 despite correct tube placement in the trachea; failure to detect exhaled CO2 may then, in turn, result in unnecessary extubation and reintubation in these critically ill newborns.
Other clinical indicators of correct endotracheal tube placement are condensation in the endotracheal tube, chest movement, and presence of equal breath sounds bilaterally, but these indicators have not been systematically evaluated in neonates. (Class IIb, LOE C) (2010 Part 15)
If the heart rate is less than 60/min despite adequate ventilation (via endotracheal tube if possible), chest compressions are indicated.
Because ventilation is the most effective action in neonatal resuscitation and because chest compressions are likely to compete with effective ventilation, ensure that assisted ventilation is being delivered optimally before starting chest compressions.
Two techniques of delivering compression have been described:
Because the 2-thumb-encircling hands technique generates higher blood pressures and coronary perfusion pressure with less rescuer fatigue, the 2 thumb–encircling hands technique is suggested as the preferred method. (Class IIb, LOE C-LD) (2015 Part 13)
Because the 2-thumb-encircling hands technique can be continued from the head of the bed while the umbilicus is accessed for insertion of an umbilical catheter, the 2-finger technique is no longer needed.
It is suggested that compressions and ventilations be coordinated to avoid simultaneous delivery. The chest should be allowed to re-expand fully during relaxation [after each compression], but the rescuer’s thumbs should not leave the chest. A 3:1 ratio of compressions to ventilation, with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate is recommended. (Class IIa, LOE C-LD) (2015 Part 13) Thus each event will be allotted approximately 1/2 second, with exhalation occurring during the first compression after each ventilation.
A 3:1 compression-to-ventilation ratio is used for neonatal resuscitation where compromise of gas exchange is nearly always the primary cause of cardiovascular collapse, but rescuers may consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin. (Class IIb, LOE C-EO) (2015 Part 13)
The Neonatal Guidelines Writing Group endorses increasing the oxygen concentration to 100% whenever chest compressions are provided. (Class IIa, LOE C-EO) (2015 Part 13) However, as of the 2015 ILCOR evidence evaluation, there were no available clinical studies of oxygen use during neonatal CPR.
Respirations, heart rate, and oxygenation should be reassessed periodically, and coordinated chest compressions and ventilations should continue until the spontaneous heart rate is ≥60 per minute. (Class IIb, LOE C) (2010 Part 15)
However, frequent interruptions of compressions should be avoided, as they will compromise artificial maintenance of systemic perfusion and maintenance of coronary blood flow. (Class IIb, LOE C) (2010 Part 15)
The current measure for determining successful progress in neonatal resuscitation is to assess the heart rate response. Other devices, such as end-tidal CO2 monitoring and pulse oximetry, may be useful techniques to determine when return of spontaneous circulation occurs.
However, in asystolic/bradycardic neonates, we suggest against the routine use of any single feedback device such as ETCO2 monitors or pulse oximeters for detection of return of spontaneous circulation as their usefulness for this purpose in neonates has not been well established. (2015 Part 13) (2015 Part 13)
Drugs are rarely indicated in resuscitation of the newly born infant.
Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step to correct it.
However, if the heart rate remains less than 60/min despite adequate ventilation with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine or volume, or both, is indicated.
IV administration of 0.01 to 0.03 mg/kg per dose is the preferred route [for epinephrine administration]. While access is being obtained, administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have not been evaluated. (Class IIb, LOE C) (2010 Part 15)
The concentration of epinephrine for either route should be 1:10 000 (0.1 mg/mL).
Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the infant’s heart rate has not responded adequately to other resuscitative measures. (Class IIb, LOE C) (2010 Part 15)
An isotonic crystalloid solution or blood may be considered for volume expansion in the delivery room. (Class IIb, LOE C) (2010 Part 15) The recommended dose is 10 mL/kg, which may need to be repeated.
When resuscitating premature infants, care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with intraventricular hemorrhage. (Class IIb, LOE C) (2010 Part 15)
Infants who require resuscitation are at risk of deterioration after their vital signs have returned to normal.
Once effective ventilation and/or the circulation has been established, the infant should be maintained in or transferred to an environment where close monitoring and anticipatory care can be provided.
After hypoxia-ischemia, lower glucose levels are associated with an increased risk for brain injury, while increased glucose levels may be protective. However, it’s not possible to recommend a specific target range of glucose concentration.
It is recommended that infants born at more than 36 weeks of gestation with evolving moderate-to- severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up. (Class IIa, LOE A) (2015 Part 13)
The use of therapeutic hypothermia in resource-limited settings (ie, lack of qualified staff, inadequate equipment, etc) may be considered and offered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up. (Class IIb, LOE-B-R) (2015 Part 13)
There is wide variation in attitudes and practice by region and availability of resources regarding management of neonates born at the margins of viability or those with conditions that predict a high risk of mortality or morbidity document.
Additionally, parents desire a larger role in decisions related to initiation of resuscitation and continuation of support of severely compromised newborns.
A consistent, coordinated and individualized approach by the obstetric and neonatal teams and the parents is an important goal.
Non-initiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely.
Parents desire a larger role in decisions related to the initiation of resuscitation and continuation of support of severely compromised newborns. The desires of the parents should be considered under circumstances when the outcome of the newly born infant remains unclear.
It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. (Class IIb, LOE C) (2010 Part 15)
There are prescribed recommendations to guide the initiation of resuscitative efforts in newly born infants. When gestational age, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples may include extreme prematurity (gestational age <23 weeks or birth weight <400 g), anencephaly, and some major chromosomal abnormalities such as trisomy 13. (Class IIb, LOE C) (2010 Part 13)
In conditions associated with uncertain prognosis where survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. (Class IIb, LOE C) (2010 Part 13)
A consistent and coordinated approach is needed from the obstetric and neonatal teams in applying these guidelines and in communicating with the parents to develop an agreed-upon management plan.
The data regarding prognostic scores are challenging to evaluate because of the difficulty in distinguishing outcomes that are driven by practice and current belief about survivability, outcomes determined by parental decision making, and outcomes affected by actual physiologic limitations of prematurity.
Antenatal assignment of prognosis for survival and/or disability of the neonate born extremely preterm has generally been made on the basis of gestational age alone. Scoring systems for including additional variables such as gender, use of maternal antenatal steroids, and multiplicity have been developed in an effort to improve prognostic accuracy.
There is no evidence to support the prospective use of any particular delivery room prognostic score presently described, over gestational age assessment alone, in preterm infants at less than 25 weeks of gestation. Importantly, no score has been shown to improve the clinician’s ability to estimate likelihood of survival through the first 18 to 22 months after birth. However, in individual cases, when counseling a family and constructing a prognosis for survival at gestations below 25 weeks, it is reasonable to consider variables such as perceived accuracy of gestational age assignment, the presence or absence of chorioamnionitis, and the level of care available for location of delivery. It is also recognized that decisions about appropriateness of resuscitation below 25 weeks of gestation will be influenced by region-specific guidelines. The most useful data for antenatal counseling provides outcome figures for infants alive at the onset of labor, not only for those born alive or admitted to a neonatal intensive care unit. (Class IIb, LOE C-LD) (2015 Part 13)
Non-initiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes.
An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants.
In infants with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop assisted ventilation; however, the decision to continue or discontinue resuscitative efforts must be individualized. Variables to be considered may include whether the resuscitation was considered optimal; availability of advanced neonatal care, such as therapeutic hypothermia; specific circumstances before delivery (eg, known timing of the insult); and wishes expressed by the family. (Class IIb, LOE C-LD) (2015 Part 13)
It is recommended that the AAP/AHA Neonatal Resuscitation Program adopt simulation, briefing, and debriefing techniques in designing an education program for the acquisition and maintenance of the skills necessary for effective neonatal resuscitation. (Class IIb, LOE C) (2010 Part 15)
In studies that looked at the preparation of instructors for the training of healthcare providers, there was no association between the preparation provided and instructor or learner performance.
Until more research is available to clarify the optimal instructor training methodology, it is suggested that neonatal resuscitation instructors be trained using timely, objective, structured, and individually targeted verbal and/or written feedback. (Class IIb, LOE C-EO) (2015 Part 13)
Studies that explored how frequently healthcare providers or healthcare students should train showed no differences in patient outcomes (LOE C-EO) but were able to show some advantages in psychomotor performance (LOE B-R) and knowledge and confidence (LOE C-LD) when focused training occurred every 6 months or more frequently. It is therefore suggested that neonatal resuscitation task training occur more frequently than the current 2-year interval. (Class IIb, LOE B-R) (2015 Part 13)
Myra H. Wyckoff, Chair; Khalid Aziz; Marilyn B. Escobedo; Vishal S. Kapadia; John Kattwinkel; Jeffrey M. Perlman; Wendy M. Simon; Gary M. Weiner; Jeanette G. Zaichkin
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John Kattwinkel, Co-Chair; Jeffrey M. Perlman, Co-Chair; Khalid Aziz; Christopher Colby; Karen Fairchild; John Gallagher; Mary Fran Hazinski; Louis P. Halamek; Praveen Kumar; George Little; Jane E. McGowan; Barbara Nightengale; Mildred M. Ramirez; Steven Ringer; Wendy M. Simon; Gary M. Weiner; Myra Wyckoff; Jeanette Zaichkin
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© Copyright 2015 American Heart Association, Inc.